THE EFFECT OF PROSTATIC INFLAMMATION ON THE OUTCOME...
Transcript of THE EFFECT OF PROSTATIC INFLAMMATION ON THE OUTCOME...
THE EFFECT OF PROSTATIC INFLAMMATION ON THE OUTCOME OF
PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA TREATED BY
TRANSURETHRAL RESECTION OF THE PROSTATE
A DISSERTATION SUBMITTED TO THE TAMIL NADU Dr. M. G. R MEDICAL UNIVERSITY CHENNAI IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
M.Ch. BRANCH – IV (GENITOURINARY SURGERY) EXAMINATION TO BE HELD IN
AUGUST 2012
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DEPARTMENT OF UROLOGY
CHRISTIAN MEDICAL COLLEGE AND HOSPITAL
VELLORE, TAMIL NADU
CERTIFICATE
This to certify that the work incorporated in this dissertation entitled “EFFECT OF
PROSTATIC INFLAMMATION ON THE OUTCOME OF PATIENTS WITH
BENIGN PROSTATIC HYPERPLASIA TREATED BY TRANSURETHRAL
RESECTION OF THE PROSTATE” is a bona fide work done by Dr. RAMYA
NAGARAJAN in partial fulfillment of the rules and regulations of M.Ch. Branch IV
(Genitourinary Surgery) examination of the Tamil Nadu Dr. M. G. R Medical
University Chennai to be held in August 2012.
Guide: Dr. Nitin Kekre, M.S., DNB Urology Professor and Head Department of Urology, Christian Medical College, Vellore
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ACKNOWLEDGEMENT Thanks to:
Prof. Nitin Kekre, HOD, Urology – for his erudition & guidance, and his
grace: by allowing me a second chance.
Dr. Arabind Panda – in whom this idea germinated first , and who
provided constant intellectual and moral support, enabling this project
to come through.
Dr. Ninan Chacko and Dr. Chandra Singh – for believing in me.
Dr. Ramani Manoj Kumar and Dr. Pradyumn Singh– for the pathology-
related input, the clinical photographs, and most importantly , for the
refreshing support received when projects got derailed.
Dr. Anuj Deep Dangi (the epitome of efficiency) – for being friend,
philosopher and guide at many a dark time.
Dr. Arun Jacob Philip George ( a fellow ship-wreck survivor) – for being
the eternal voice of reason , along with providing that much-needed
comic relief, to beast and (wo)man.
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Drs. Johann and Deborah – for their prompt response to S.O.S signals.
Dr. Pradeep Kulkarni – who helped me navigate many muddy waters.
Drs. John, Mukha and Nirmal, – for being helpful seniors.
Dr. Nihal Thomas – for support with the IRB protocols.
Dr. J.P. Muliyil for accepting phone calls about vague statistics and
patiently responding.
Mr. Jeyaseelan, for making statistical sense out of a quagmire of data.
Mr. Balaji – for being the ultimate secretary.
All my friends and colleagues in the Department – for being supportive
pressure-vents.
My sister Lavanya, B.I.L.Rajesh, Krish (and the soon-to-arrive bundle ! )
– for regular Skyping and mood-spiking.
Most important of all , my Parents – for proof that gods aren’t
necessary, when you have Parents .
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ACKNOWLEDGEMENTS
S. No. Title Page No.
1. Abbreviations 6
2. Abstract 7
3 Introduction 9
4. Review of Literature 10
5. Aims and Objectives 19
6. Materials and Methods 20
7. Observation and Results 21
8. Discussion 42
9. Conclusions 44
10. Bibliography 45
11. Proforma 49
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ABBREVIATIONS
5-ARI: Five alpha reductase inhibitor
AIP: Asymptomatic inflammatory prostatitis
BPH: Benign prostatic hyperplasia
COAD: Chronic obstructive airway disease
CPPS: Chronic prostatitis/ pelvic pain syndrome
CRF: Chronic renal failure
DRE: Digital rectal examination
IRB: Institutional review board
LUTS: Lower urinary tract symptoms
MI: Myocardial infarction
MS: Meatal stenosis
NIH: National Institute of Health
Pi: Prostatic inflammation
S.D.: Standard deviation
TUR Syndrome: Transurethral resection Syndrome
TURP: Transurethral resection of the prostate
US: Urethral stricture
UTI: Urinary tract infection
Group A= Absence of prostatic inflammation (Pi-)
Group B= Presence of inflammation (Pi+)
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ABSTRACT
AIM:
To evaluate the role of asymptomatic prostatitis found in biopsy
specimens on the outcome of patients undergoing a TURP for BPH.
PATIENTS AND METHODS: All patients who had undergone a TURP between 2005 and 2010 in our
institute for BPH and who had a minimum of 3 months follow-up were
included. The study population was divided into two cohorts: those with,
and those without prostatic inflammation. The outcomes between these
two groups were compared with respect to predefined parameters,
including demographic data, indication for TURP, positive preoperative
urine cultures, presence of a urinary catheter, duration of follow-up,
weight of gland resected, monopolar / bipolar resection, need for blood
transfusion, emergency re-explorations, TUR syndrome, clot retention,
recatheterisation; Long term complications like meatal stenosis, urethral
stricture, bladder neck contracture, and recurrent adenoma were also
noted. The modified Clavien system for TURP was used for reporting
complications.
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RESULTS: There was no significant difference between both the groups both with
respect to long-term and short term complications.
CONCLUSIONS:
Prostatic inflammation may be a co-incidental finding in the biopsy of
patients undergoing a TURP. The association between both short term
and term complications and the presence of prostatitis could not be
demonstrated in our study. Larger prospective trials may be needed to
further validate these findings.
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INTRODUCTION
The co-existence of inflammation and BPH in the prostate is well-
known, although the significance of histologically proven prostatic
inflammation and its relationship with BPH is not well-understood1.
While prostatic inflammation may play a role as an inciting even in the
development of BPH nodules, its role as the next link in the chain of
events after treatment has not been elucidated2. Asymptomatic
prostatitis (Category IV of the NIH Classification of Prostatitis)3 is a well-
recognised entity noted in TURP biopsy specimens. Pathological
consensus dictates that chronic inflammation must typically involve the
prostate in a peri-glandular distribution, to be considered prostatitis.
Diffuse stromal infiltrates or focal lymphoid aggregates in the stroma
may be seen ubiquitously, and are considered to be of no clinical
significance4. Few studies exist on the influence of this chronic
prostatitis seen after TURP on patient outcomes after the procedure.
Bucuras et al compared two groups with and without chronic prostatitis
in the TURP biopsy specimens and found no significant difference in
intra-operative and post-operative complications between them5. A
study by Doluoglu, however found prostatic inflammation to be a
significant factor for the development of urethral stricture and bladder
neck contractures after TURP6. Our study was conducted to look into
this controversial issue and see if an association truly exists.
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REVIEW OF LITERATURE
The human prostate is an immunocompetent organ, harbouring a
smattering of inflammatory cells that populate the stroma and the
epithelium. As age increases, the number of T&B lymphocytes,
macrophages and mast cells within the prostate also increases. Chronic
inflammation of the prostate has a characteristic histological signature,
consisting mainly of CD3+ and CD4+ T lymphocytes (70-80%), CD19 or
CD20 B lymphocytes (10-15%) and macrophages (15%).
Prostatic inflammation is a nebulous term, with no clear-cut definition as
to what constitutes it, histologically. A clinical definition of what
encompasses prostatitis is partly laid down in the chronic pelvic pain /
CPPS syndrome classification system. Molecular studies have only now
enabled the identification of the types of inflammatory cells that populate
the prostate, leading to some clarity. The earliest attempt to arrive at an
accepted histological classification of prostatitis was made by Kohnen at
al in 1978. They described 6 morphologically distinct patterns (Figs. 1 &
2) of prostatic inflammation based on analysis of prostatectomy
specimens –
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(i) Segregated glandular inflammation,
(ii) Peri-glandular inflammation
(iii) Diffuse stromal inflammation,
(iv) Isolated stromal lymphoid nodule
(v) Acute necrotizing inflammation
(vi) Localized granulomatous inflammation.
Irrespective of the presence of disease, chronic prostatitis is most
commonly characterized by a lymphocytic infiltrate in the stroma
immediately adjacent to the prostatic acini, a finding re-established by
Nickel et al6. Stromal infiltrates often co-exist with peri-glandular peri-
glandular inflammation, but their presence can be ubiquitous8.
Inflammatory cell infiltrates had been noted in the prostatic tissue of
patients with BPH in Kohnen’s study, and there have been many
studies which reveal that these two entities often co-exist8. The clinical
relevance of this association, however, remains a mystery.
Evidence exists for chronic inflammation as an etiological agent in
many human cancers like stomach, large bowel and liver. The
temptation to draw a parallel for development of neoplasia in chronically
inflamed prostates held immense appeal for many investigators, and a
link between prostatitis and prostate cancer was sought10.
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Prostatic inflammation was found in more than 2/3rds of men in the
REDUCE trial. Prostatic tissue in BPH was found to have chronic
inflammation in ~43% of specimens, as reported by Di Silverio8. Areas
of chronic inflammation frequently occur in radical prostatectomy
specimens, prostatic biopsies, and autopsy material9,10. The link
between the presence of inflammation, BPH has also been explored,
with Nickel even questioning if it is the missing 'third' link in the
pathophysiology of hyperplasia along with its static and dynamic
components11.
There thus exists a dichotomy in the world of prostatitis, with
pathologists defining it as an increase in the prostatic parenchyma
while the urologist’s view is a clinical one. The classical definition for
the urologist has been a syndrome characterized by lower genitourinary
tract pain/discomfort and inflammatory cells seen in the expressed
prostatic secretions. These syndromes were together incorporated into
a single classification of the chronic prostatitis/pelvic pain syndromes
(CPPS) by the NIH group3.
The NIH consensus classification of prostatitis syndromes includes 4
categories:
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I Acute bacterial prostatitis
II Chronic bacterial prostatitis
III Chronic prostatitis/chronic pelvic pain syndrome
A. Inflammatory
B. Non-inflammatory
IV Asymptomatic inflammatory prostatitis
Category IV of the NIH classification comprises prostatitis detected
incidentally on biopsy, and is called asymptomatic prostatitis. Therapy
is not deemed necessary for this group, as these patients are by
definition asymptomatic. The incidence of asymptomatic prostatitis has
been found to be 43-98% in surgically resected prostates for BPH11 .
The clinical significance of finding asymptomatic prostatitis in TURP
specimens has not been clearly elucidated. BPH is the most common
disease affecting old men with an estimated 70% incidence at 60-70
years, with increasing incidence and prevalence with age12. As the
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incidence increases, an increasing number of patients will eventually
require surgery as an end-point of disease progression.
TURP remains the gold standard treatment for surgical management of
BPH. The likelihood that a person will require TURP increases by 6, 14
and 8 times with each completed decade after 59 years. After its
introduction in the early 20th century, the morbidity and mortality
associated with TURP has steadily fallen with progressively increasing
instrumental and technical advancements.13 The risk of intra-operative
complications like cardiac events and TUR syndrome is small but real.14
The advent of bipolar TURP technology arose from the need to
overcome the peri-operative and post-operative morbidity of
conventional monopolar TURP.
Meatal stenosis and strictures of the urethra are major late
complications after TURP. The former usually occur due to discrepancy
in size between the resectoscope sheath and the meatal diameter 15.
Urethral strictures, on the other hand are proposed to be caused by
mechanical and thermal stress to the urethra, along with inappropriate
lubrication, incorrect axial and rotating movements of the resectoscope,
longer periods of operative time, and with prolonger catheterization
times16. The incidence of meatal stenosis /urethral strictures and
bladder neck contractures in contemporary series is reportedly to the
tune of 2.2-9.8% and 0.3-9.2% respectively14.
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With regards to bladder neck contractures after TURP, it has been
suggested that performing a bladder neck incision after TURP in
patients with small prostates may be beneficial18, 19.
The role of chronic inflammation seen after TURP in influencing
outcomes after TURP has not been extensively evaluated. Bucuras et
al retrospectively analysed 200 consecutive cases of BPH with no
history of chronic prostatitis. Two groups were identified from these
depending on whether the prostatic tissue harboured inflammation or
not. There were no significant differences concerning intra-operative
and postoperative complications between the two groups, barring acute
urinary retention, which was more frequently seen both before and after
surgery in patients with prostatitis. The authors concluded that further
studies were needed to elucidate this problem more clearly.20
A similar study by Doluoglu et al was conducted to evaluate the
relationship between pathologically proven prostatic inflammation and
re operation rates due to stricture urethra and bladder neck stenosis
occurring after TURP. Retrospective data on 917 patients was
reviewed with respect to the presence or absence of inflammation in
the biopsy specimen after TURP. These two groups were compared
with respect to the descriptive data and need for re-operation. It was
found that the re operation rate in the group with prostatic inflammation
was significantly higher than that without chronic prostatitis (29.8% vs.
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8.6%, p=<0.0001). It was proposed that prostatic inflammation seen on
TURP histopathology was an independent variable affecting the
development of urethral stricture or bladder neck contracture.21
While considering the complications and pre-operative risk factors the
use of pre-operative anticoagulant use, anti platelet use, pre-operative
catheter placement, larger prostate size, use of monopolar /bipolar
cautery etc. have all also been demonstrated to have an impact on
outcome.22
With increasing need for a standardized method of reporting
classification, the Clavien system was introduced in 1992, and later
modified in 2004.23 This modified Clavien- Dindo system was
introduced across all surgical disciplines, including urology, improving
the detection of often un-reported and minor complications. Improved
detection thus culminated in less observation bias, especially in
retrospective studies. Mamoulakis et al suggested the use of this
system to allow for an objective, standardized and detailed comparison
of reporting complications of TURP.24 The majority in their series were
those with Grade 1 or Grade 2, with one death (Grade 5).
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AIM
1. To study the outcome variables between two patient cohorts with
the absence or presence of inflammation identified histologically in
their TURP specimens.
2. To determine the role of asymptomatic prostatitis in the
development of short term and long term complications after a
TURP
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PATIENTS AND METHODS
DESIGN AND LOCATION: This hospital based historical cohort study was conducted at the
Department of Urology, Christian Medical College, Vellore.
PATIENTS: All patients who underwent a TURP in our hospital between 2005 and
2010 who satisfied the following inclusion and exclusion criteria were
recruited:
INCLUSION CRITERIA: 1. Patients with a minimum follow-up of 3 months.
2. Patients whose biopsy showed BPH with/without glandular/peri-
glandular stromal inflammatory infiltrates suggestive of prostatitis.
3. Absence of chronic perineal/pelvic pain ( i.e. patients classified to
have Asymptomatic inflammatory Prostatitis - Category IV of the
NIH Classification of Prostatitis)
EXCLUSION CRITERIA: 1. Patients undergoing TURP with a concomitant procedure (for
eg.hernioplasty/circumcision/cystolitholapaxy).
2. Patients who had a histological diagnosis of carcinoma prostate.
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3. Prior history of urethral instrumentation.
4. Biopsy patterns showing scattered/focal stromal inflammatory
infiltrate without any acinar/peri-glandular involvement.
DURATION: Patients operated at our institution between January 2005 and
December 2010 were included.
METHODOLOGY: Patients who underwent a TURP at our institute during the
aforementioned study period and fulfilling the inclusion criteria detailed
above were selected for inclusion in the study. Prior to surgery, all
patients were subjected to a thorough history-taking & physical
examination. IPSS, serum biochemistries, urine analysis, and urine
cultures were documented. Serum PSA was not sent routinely. Patients
on anti platelet therapy were asked to discontinue the drug for a period
of a week pre-operatively. A detailed proforma was filled up for each
patient recording the data to be assessed. Informed consent was taken
in the appropriate format. In accordance with institutional policy an IRB
committee clearance was obtained for the study. The TUR-P was
performed using the same technique in all cases with the use of a 26F
continuous irrigation resectoscope and with either a bipolar or
monopolar energy source. A BNI was added to at the end of the TURP
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in those noted to have a small gland intra operatively. Patients with a
biopsy showing presence/absence of inflammation who had a minimum
of 3 months follow-up were included (150 in each cohort) and analysed.
Re-interventions for complications were performed in the event that the
patient presented at a later date with a poor flow, with uroflowmetry
showing an average Q max of less than 10 ml/second.
DETAILED METHODOLOGY: FOLLOW-UP:
Only those patients having a minimum follow-up of 3 months after the
TURP were included, as the mean time reported for complications like
bladder neck contracture is reported as 2 months17.
INDICATION FOR TURP
These were classified as chronic retention, acute retention, acute on
chronic retention, failure of medical management, obstructive
nephropathy, recurrent urinary tract infections (UTIs), recurrent
hematuria or highly bothersome LUTS. If more than one indication
existed, the single most significant one was taken for consideration.
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USE OF PRE-OPERATIVE 5 –ALPHA REDUCTASE INHIBITORS
Prior use of any of the 5-Alpha reductase inhibitors (Finasteride or
Dutasteride) either alone or in combination with alpha-blockers was
noted. This was included due to the known effect of reduction in
prostate gland volume associated with this class of drugs, which in turn
could have an effect on outcomes after TURP.
PRE-OPERATIVE URINARY CATHETER
Presence or absence of a pre-operative urinary catheter was noted.
CO-MORBIDITIES
The associated patient risk factors which could affect peri-operative
mortality/morbidity like diabetes mellitus, hypertension, ischaemic heart
disease, chronic obstructive pulmonary disease, anticoagulant use, anti
platelet use and chronic renal failure were noted. The patients were
then grouped into those who had single, multiple, or no co morbidities
in the final analysis.
DIGITAL RECTAL EXAMINATION
Pre-operative DRE assessment of the gland size was recorded.
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IMMEDIATE POST-OPERATIVE COMPLICATION
To ensure for uniformity in reporting complications, the modified
Clavien system for TURP proposed by Mamoulakis et al. was used.24
The complications were graded from Clavien grade 1 through grade 5.
LONG TERM COMPLICATIONS
The occurrence of meatal stenosis, urethral stricture, bladder neck
contracture or recurrent adenoma was noted on follow-up. All these
patients underwent re interventions for the complication (viz. Meatal
dilatation/meatoplasty/endoscopic internal urethrotomy EIU /urethral
Teflon dilatation or bladder neck incision).
RESECTED GLAND
The actual weight of the resected prostatic tissue (in grams) was
recorded.
PRESENCE OF PROSTATITIS
The presence of inflammatory infiltrate in a location characteristic for
prostatitis (viz. periglandular stroma, glandular epithelium and
intraglandular luminal sites) was identified based on the biopsy report
and patients with/without prostatic inflammation and adequate follow-up
were included, to attain the sample size of 300. Presence of scattered
or focal stromal inflammatory infiltrates alone was not included.
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PRE-OPERATIVE URINE CULTURE
This was obtained as a suprapubic aspirate/ mid-stream clean catch or
catheter sample. Patients with significant pre-operative urine cultures
were treated for a minimum of 3 days with a course of culture-specific
antibiotics. Colony counts of >100,000 c.f.u was considered significant.
POST-OPERATIVE URINE CULTURE
This was obtained after the TURP procedure either as a voided sample
or a catheter sample in those who had failed bedside TWOC post-
operatively. Patients with significant post-operative urine cultures were
treated for a minimum of 3 days with a course of culture-specific
antibiotics. Colony counts of >100,000 c.f.u were considered significant.
STATISTICAL ANALYSIS: Sample size calculation: Based on previous studies in contemporary
literature14,17 the expected mean difference in complications between
those with (10%) and without (2%) prostatic inflammation was kept at
6%. The number needed to detect a significant difference, keeping the
power at 80%, was calculated to be a minimum of 140 in each arm. We
finally included 300 subjects (150 in each group) in the study.
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Statistical package for social science (SPSS) version 16.0 was used for
statistical analysis.
The results were grouped into two groups: Group A included patients
with a pattern of prostatic inflammation seen in the biopsy specimen
after TURP and Group B included patients in whom there was none. .
Student’s T-test was used to compare quantitative variables between
the groups and the Pearson’s Chi-squared test was used to analyse
association with complications qualitatively. Mean ± standard deviations
were used for normally distributed data and median & range (min –
max) was used for skewed data to avoid the outlier effect. The Mann-
Whitney U test was used to assess variables not following a normal
distribution. A p value of ≤ 0.05 was taken as significant.
RESULTS
Total number of patients who underwent a TURP between 2005 and 2010
n = 945
Biopsy showing BPH n = 822
Did not me
criteri
TABLE 1
Study population n = 300
et inclusiona= 522
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TABLE 1
Variable
Group A (Pi-)
Mean±S.D.
Group B (Pi+)
Mean±S.D.
p value
Age
(years)
63.79+8.04 64.41+7.76 0.49
DRE gland size
(grams)
31.83+10.5 31.92+9.93 0.90
Resected
weight (grams)
20.9+18.15 23.2+14.95 0.16
Hospital stay
(days)
6.21+2.57 6.17+2.21 0.38
Follow-up
(months)
24.9+21.07 20.9+18.15 0.12
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TABLE 2
Comorbidities
Group A (Pi-) %
Group B (Pi+)
%
p value
None 44% 32%
Single 32% 48%
Multiple 24% 20%
1.08
TABLE 3
Preoperative ARI use
Group A (Pi-) %
Group B (Pi+)
%
p value
Used 20% 14%
Not used 80% 86% 1.94
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TABLE 4
Preoperative catheter
Group A (Pi-) %
Group B (Pi+)
%
p value
Absent 54% 53%
Present 46% 47%
0.45
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TABLE 5
p value Indication Group A (Pi-) %
Group B (Pi+)
%Chronic
retention
9.4% 11.3%
Acute retention 18.8% 21.3%
Acute on
chronic
retention
17.4% 15.3%
Failure of
medical
management
43% 32%
Obstructive
nephropathy
0% 0.7%
Recurrent UTI 2% 3.3%
Recurrent
hematuria
1.3% 2.7%
Bothersome
LUTS
8.1% 13%
0.4
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TABLE 6
Energy source Group A (Pi-) %
Group B (Pi+)
% p value
Monopolar 91.3% 91.3%
Bipolar 8.7% 8.7% 0.58
TABLE 7
Blood transfusion
intra-operatively
Group A (Pi-) %
Group B (Pi+)
%
p value
Given 96% 4%
Not given 93% 7% 1.08
TABLE 8
Surgery performed
Group A (Pi-) %
Group B (Pi+)
%
p value
TURP 95.3% 94%
TURP + BNI 4.7% 6% 0.39
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TABLE 9
Clavien Grade 1
Complications
Group A (Pi-) %
Group B (Pi+)
% p value
None 81% 70.7%
Hematuria 1.4% 3.3%
Clot retention 2% 1.3%
Blocked
catheter
0% 0.7%
Bedside failed
TWOC
2% 2.7%
Transient rise
of creatinine
2% 0%
Post-operative
UTI requiring
antibiotics
10.8% 21.3%
0.06
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TABLE 10
Clavien Grade 2 Complication
Group A (Pi-) %
Group B (Pi+)
% p value
None 95.3% 97.3%
Hemorrhage
requiring blood
transfusion
2.7% 1.3%
UTI with
septicemia
0.7% 1.3%
Supraventricular
tachycardia
1.3% 0%
Pulmonary
embolism
0% 0%
0.39
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TABLE 11
Clavien Grade 3
Complication
Group A (Pi-) %
Group B (Pi+)
% p value
No
re-exploration
97% 98.7%
Re-exploration
with anesthesia
3% 1.3% 0.248
TABLE 12
Clavien Grade 4
Complication
Group A (Pi-) %
Group B (Pi+)
% p value
TUR Syndrome 4% 1.3%
MI 0% 0% 0.14
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TABLE 13
Long term complications
Group A (Pi-) %
Group B (Pi+)
% p value
Meatal stenosis 2% 3.3% 0.51
Stricture
urethra
6%% 6.7% 0.64
Bladder neck
contracture
3.3% 5.3% 0.72
Recurrent
adenoma
2% 3.3% 0.51
TABLE 14 OVERALL INCIDENCE OF LONG TERM COMPLICATIONS
LONG TERM COMPLICATION Total n= 300(%)
Meatal stenosis 7(2.3%)
Urethral stricture 18(6%)
Bladder neck contracture 11(4.3%)
Recurrent adenoma 8(2.6%)
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RESULTS The two groups of patients were divided based on the absence or
presence of prostatitis.
GROUPA GROUPB
Prostatitis absent (Pi-) Prostatitis present (Pi+)
PATIENT PROFILE
The study group comprising 300 patients had an overall mean age of
64 years (range 47-88). All the patients had an average hospital stay of
6 days, including the dates of admission and discharge. The mean
gland size of the group was 32 grams and the mean resected weight
was 22 grams. We had kept a minimum follow-up criterion as 3 months,
and the mean follow-up duration noted in our study was 22 months.
The longest duration of follow-up among all the groups was 72 months.
The baseline demographic data compared between Group A and B
revealed a similar distribution of age, gland size on DRE, hospital stay,
and follow- up, suggesting both the groups were homogeneous in
composition.
37
The comorbidities between the groups showed a similar pattern. There
was a slightly higher incidence of patients with multiple co-morbidities in
Group A (24%). Group B showed a higher incidence of patients with a
single co-morbidity, the most common of which was hypertension.
Overall the most common co-morbidity among our patients was
hypertension, followed closely by diabetes mellitus. COAD, ischemic
heart disease, chronic kidney disease and anti-platelet use were the
other co-morbidities noted
in the study group, but these were not analysed individually.
A small proportion of our patients had been on Alpha-reductase
inhibitors preoperatively. This was uniform in both the groups- 14% and
20% in group A and B respectively. The remainder either did not report
use of this drug or had not been started on it. The difference between
use in group A and B was not significant
(p= 1.94).
Around 50% of the patients in both group A and group B were on
catheters preoperatively , showing that both groups has a similar
patient profile, preventing potential skewing of data.
The most common indication between for both groups was failed
medical management, which was slightly more common in group A
(43% vs. 32%). This was not however a significant difference. The
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other indications in decreasing order of importance were acute
retention, chronic retention, acute on chronic retention, recurrent
hematuria and recurrent hematuria. There were no cases of obstructive
nephropathy in group A, but this was again not of significant on
comparison between the two groups.
The use of monopolar and bipolar current as energy sources showed
remarkable similarity between the two groups. Monopolar cautery was
the predominant source of energy used, with the use of bipolar was
approximately 9% in both the groups.
The intra-operative use of blood products between the two groups also
was similar , with an overall average transfusion rate of ~5%. The
transfusion given post-operatively due to hematuria in the ward was
recorded separately using the Clavien classification ( vide infra).
The surgery performed in most cases was a TURP , which had a
similar incidence in groups A and B. The addition of a BNI failed to
make a difference in outcome between the two groups. The overall
incidence of concomitant BNI performed in our series was 5%.
On analysis of the short term complications as recorded by the Clavien
system , it was noted that the most common Clavien complication was
39
the post-operative use of antibiotics for UTIs. These were either
symptomatic or asymptomatic with significant colony counts, which
were treated with a course of antibiotics. Though a seemingly higher
incidence of post-operative UTIs was seen in group B , this difference
was not statistically significant. The next most common Clavien 1
complication was hematuria noted in the post-operative period, which
required irrigation and removing the catheter a few days later , as and
when the catheter effluent was clear. The incidence in the two groups
of bedside failed TWOC was 2% and 3% in the groups. These patients
were recatheterised and had a successful trial void at a later date on an
OPD basis. There was a small 2% incidence of transient creatinine rise
in group A, which again was not significant. Overall the two groups
showed no significant difference in Clavien 1 complications.
Clavien grade 2 complications were again rare, with the most common
one being hematuria requiring blood transfusion in the post-operative
period. This incidence in our series was 2.7% in group A and 1.3% in
group B, with the mean overall postoperative transfusion rate being
1.5%. A small percent of both the groups progressed to have UTI with
septicemia, requiring a two-week course of antibiotics, This was seen
with a similar incidence in both the groups, and the the presence of
inflammation in the biopsy did not have any statistically significant
association with the occurrence of this morbidity. 2 patients developed
40
ECG changes intra operatively, requiring a shift to SICU in the
immediate post-operative period, These were not associated with any
cardiac enzyme elevations and they subsequently had no
complications. There was no incidence of pulmonary embolism in both
the groups. The overall p value between the two Clavien grade 2
groups was 0.9, suggesting no statistically significant difference.
In the post-operative period 3% of patients in Group A required re-
exploration for clot evacuation subsequent to postoperative bleeding .
The corresponding incidence in group B was 1,3%, showing that there
was no difference in Clavien grade 3 complication rates.
Group A was noted to have a 4% incidence in postoperative TUR
syndrome, though no obvious cause was evident for this. On statistical
analysis failed to highlight a possible association prostatitis and the
occurrence of TUR syndrome. None of the patients had an MI in either
of the groups.
There were no Clavien grade 5 complications reported in either of the
groups, making a comparison impossible.
Finally, analysis of the long term complications between both group A
and group B (with respect to meatal stenosis, urethral stricture
formation, bladder neck contracture or recurrent adenoma) also
showed no statistical significance.
41
DISCUSSION
The significance of finding chronic prostatitis in the biopsy specimens of
patients undergoing a TURP has been debated.
While some authors reported an association with outcomes, other
researchers failed to demonstrate a definite link of association between
this pathological entity and clinical outcomes after TURP.
The study was initiated to address the role of asymptomatic prostatitis
found incidentally on TURP specimens and to look for an association
with either long term or short term outcomes. Our baseline
demographic data showed that both the groups (Group A and Group B)
had a similar clinical profile , suggesting that both the study populations
were homogeneous. The placement of pre-operative catheter, 5ARI
use, presence of single versus multiple comorbidities , pre-operative
positive urine cultures , gland size, energy source used ( monopolar or
bipolar ) or resected glandular tissue weight did show any statistical
significance between the two groups. The immediate short term
complications were stratified into 5 Clavien Grades , and these also
failed to show any association with the presence or absence of
asymptomatic prostatitis. Finally , the occurrence of long term
complications (which have been hypothesized to be the sequelae of
chronic inflammation and irritation) was found to be the same across
both the groups, putting the hypothesis of inflammation as a cause for
42
long term complications into question. The overall incidence of both
long term complication in our case series(2.3%, 6%, 4.3% and 2.6 %
for meatal stenosis , urethral stricture, bladder neck contracture and
recurrent adenoma respectively) is comparable with that found in
contemporary series on TURP complication rates14.
43
CONCLUSIONS
1. Presence of prostatitis on histopathology did not alter the outcome
of patients who underwent a TURP.
2. Short term and long term complications of TURP had no
association with the finding of prostatitis in the biopsy.
Asymptomatic prostatitis was merely a co-incidental finding in the
biopsy of patients undergoing a TURP.
44
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48
PROFORMA
1. Name:
2. Age:
3. Hospital number:
4. Address:
5. Phone number:
6. Hospital stay(days):
7. Follow-up duration (months):
8. Pre-operative positive urine culture: Y/N
9. Pre-operative antibiotics course:Y/N
10. Indication for TURP: Chronic retention/ acute retention/ acute on
chronic retention/ failed medical management/ poor flow/ recurrent
UTI/ recurrent hematuria/ bothersome LUTS
11. Co morbidities: Absent/single/multiple {Specific details: }
12. Pre-operative urinary catheter: Y/N
13. DRE gland size (grams):
14. Energy source: Monopolar/bipolar diathermy
15. Blood transfusion: Y/N
16. Gland resected (grams):
17. Biopsy showing chronic prostatitis: Y/N
18. Post-operative positive urine culture: Y/N
19. Post-operative complications: Y/N
20. Clavien grade of complication: 1/2/3/4/5 {Specific details: }
21. Long- term complications: Meatal stenosis/urethral stricture/bladder neck
contracture/residual prostate